Healthcare Reform and Your Cervix

The wheels were coming off the Health Reform Express even before last week, when a pair of exquisitely timed proclamations about breast and cervical cancer screening sent it careening into a fog thicker than December in Cornwall.

For those who don’t want the American people to see that the US health care system already rations care, and those who profit from its inefficiencies and lack of oversight, last week’s expert panel statements couldn’t have been scripted better by the Bard himself.

With this twist, the “debate” over Health Reform—such as it was—has completely devolved into a 3-ring circus.

If you don’t believe this, turn on the tube and watch some coverage of the announcements.


On one channel, a feminist militant dukes it out with a former NIH director! On the next, Doctors with Wombs battle Poor Slobs with Testicles! And on a third, the HHS Secretary performs a Reverse Moonwalk the likes of which we haven’t seen since Thriller, instead of actually reading the Senate’s draft proposal on health reform.

Really, Ms. Sebelius, is that too much to ask? No wonder your Commander in Chief looks increasingly ready for a squirt-and-rinse with Just for Men.

Although the task forces’ new guidelines for mammography and Pap tests were not overtly designed to cut costs, they do reflect an attempt to rely on objective evidence. Whether such efforts are brazen, long overdue or something else, they are unquestionably the sort of thing Obama embraced when he set aside $2 billion for Comparative Effectiveness research as part of ARRA.

But Mr. President! Surely you knew that biological systems can’t be dumbed-down to Newtonian physics, where F = MA and if you plug and chug the numbers, you get a definitive answer. So you must have known this was coming, right?

"One of the things you're seeing is the maturation of the concept of evidence-based medicine," Ned Calonge understated to the Washington Post as he surveyed the damage. Calonge chaired the federally appointed task force that issued those combustible mammography guidelines last week.

The US spends $5 billion per year on mammograms. Calonge’s task force had reasoned that although the test reduces breast cancer mortality overall, its deployment beginning at the age of 40 came with a cost it deemed too high…at least too high to merit a blanket statement. Tens of thousands of women would be exposed to radiation from additional testing, and to biopsies, surgeries, radiation and chemotherapy to treat tumors that may never be life-threatening.

Though certain elements of the Sink Obama or Bust Crowd conveniently overlooked it, the task force did not recommend denying mammograms to women in their 40s, only that the decision should rest with doctors and their patients who could evaluate the unique features of each case such as family history of breast cancer, comfort living with uncertainty and so forth.

This Crowd, by the way, is the same group that railed for months about how government-run health care would intercede between the doctor and her patient, but never mind that.

The task force’s recommendations were based on calculations that for women in their 40s, frequent mammograms prevent one cancer death for every 1,904 women screened. That number decreases to one death prevented for every 1,339 women from 50 to 59, and to one death for every 377 women from 60 to 69.

Yes, the numbers are stark and frightening, but credit the group for being explicit. How is this rationing so different from decisions to underfund Medicaid, to not cover preventive services and lest we forget, leave totally uninsured a group of Americans equal in size to the entire population of England?

As for the management of your cervix, the American College of Obstetricians and Gynecologists pushed back the date to age 21 when women should receive their first Pap test, and reduced the recommended screening frequency from every year to every other year for women in their 20s.

ACOG made these recommendations after determining that the tests and subsequent interventions were leaving too many women with scars that led to pregnancy and birthing problems, and if backing off on screening a bit meant losing a few women to cervical cancer, so be it.

Another painfully stark trade-off, but somehow this one seemed to pass muster in the public eye. Go figure.

Alas this will take years to play out. Americans are consumers of health care. That means the more the better, and money is no object when a life is at stake (especially when it is someone else’s money).

Last week’s announcements poured a bucket of ice water on these beliefs, but they are too strong to be doused immediately. There was sizzle and smoke, but the fire still burns.

A transformation in thinking is required, and the short-term prospects for that are dim, indeed.

In 1847, Hungarian physician Ignaz Semmelweis (pictured) showed that hospital-acquired infections could be drastically reduced if caregivers would just wash their hands. To this day, only half of all hospital employees follow his recommendations.

Glenn Laffel MD, PhD
Sr. Vice President, Clinical Affairs, Practice Fusion